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South African midwives caring for immigrant and refugee women

The midwife assumes a variety of roles – advocate, adviser, confidante, decision maker, custodian, teacher and coordinator of care. As cultural diversity intensifies, the need for specialised knowledge in performing these roles increases; specifically, midwives need to be skilled in bridging cultural barriers.

In South Africa every midwife is expected to care for a pregnant woman irrespective of her race, colour, ethnicity, religious group or nationality, and the therapeutic relationship between a midwife and patient can be adversely affected if the midwife is ethnocentric, xenophobic or poorly trained in the values of their profession or communication skills.

In public hospitals some clinical facilities do not have sufficient staff and equipment, and this has resulted in some midwives feeling that resources should be used for South Africans only. It appears that immigrant women are not receiving the same care as local women (or are treated differently), and there is a feeling among pregnant immigrant women that they are treated unkindly because they are foreigners and refugees.

Language barriers between midwives and pregnant immigrant women have a negative impact during labour. Immigrant women are made uncomfortable by the difficulties they experience in communicating with the staff, the frequent impossibility of following advice given and the reaction of the midwives. The immigrant women find the midwives rude during labour, yet the lack of knowledge of their language makes it difficult to understand what they want from them; even intonation, voice quality, vocabulary, silence may all have different meaning in different cultures. A midwife who is not aware of these may disrespect an immigrant woman unintentionally.

“They told me they cannot attend to me because I am an immigrant, I don’t have papers, I didn’t have any proof of residence.”

Women who receive antenatal care early in pregnancy and who have more antenatal visits tend to have lower maternal and antenatal mortality and better pregnancy outcomes. However, pregnant immigrant women are often turned away from these services because of lack of documentation; high levels of complaints about their antenatal care have remained constant over past decades.

Immigrants have stated that their relationship with the midwives is not cordial, and can actually be alarming, and attribute the lack of personal care to their being immigrants. Many immigrant women say they are addressed in a derogatory manner and called by names which indicate that they are from foreign countries. Immigrant women are often left alone or verbally abused or threatened with physical assault, leaving some of them with post-traumatic stress.

“The nurses that I met were not even ready to look at my face…’’

Despite midwives’ commitment to respect for the human being, her dignity and privacy, personal values, beliefs and cultural traditions, pregnant immigrant women much of the time have no right to make decisions and their beliefs and cultural practices are often ignored. Most immigrants do not get the care and support they are entitled to.

Recommendations and challenges

Educators in nursing colleges and universities should place greater emphasis on cultural sensitivity in midwifery care. Midwives should be trained in client relations and in communication skills and should be encouraged to attend workshops on human rights and cultural issues.

Some midwives feel that they are not obliged to speak English with immigrants as they think the women should have learned at least one South African language. Where immigrants cannot communicate even in English, interpreters should be used, despite the potential compromise of confidentiality between midwife and the pregnant woman. Otherwise midwives could include the spouse or members of the family for the purpose of communication and support.

Finally, the management of hospitals should provide front-line staff with clear guidelines on how to admit or register immigrants and should assist in administrative matters to empower the midwife to render culturally sensitive care.


Mamokgadi Gloria Victoria Koneshe
Midwifery lecturer, Ann Latsky Nursing College, Johannesburg, South Africa

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